Myxofibrosarcoma (MFS) is the second most common subtype of soft tissue sarcoma (STS) and is associated with a high rate of local recurrence after resection. These tumours frequently present with peri-lesional edema, termed “tumour tails” on staging MRI scans [1]. Tumour tails(TT) may contain satellite neoplastic cells or can represent benign reactive edema. There are no clear radiological features to distinguish malignant from reactive peri-lesional edema which limits accurate surgical planning, resulting in either high rates of inadvertently positive resection margins and local recurrences or overly-aggressive resections which negatively impact function and increase morbidity [2]. The objective of this pilot study was to prospectively study a cohort of MFS patients with TTs in an attempt to identify radiological features that predict which type of edema is malignant and requires resection together with the main tumour mass.

Patients diagnosed with MFS on biopsy at an orthopaedic oncology referral centre between January 1-December 31 2018 who also had TTs on staging MRI scans were prospectively recruited for the study. Tumours were treated with wide surgical excision, including the TTs, and (neo)adjuvant radiotherapy as per institutional protocol. Staging MRI scans were reviewed in a blinded fashion by two musculoskeletal radiologists to distinguish malignant from reactive TTs. The main tumour mass underwent standard histological evaluation while the regions encompassing the TTs were photographed and sectioned into grids. Each tissue section was examined histologically for the presence of satellite neoplastic cells based on morphological criteria. Radiological and histological findings were compared.

Six patients met the inclusion criteria and underwent analysis. All tumours were located in the extremities and were deep to fascia. Mean age at presentation was 67 years (range 51 – 85), with a male:female ratio of 4:2. All patients received radiotherapy (50 Gy), either pre- (n=4) or post-operatively (n=2) based on multidisciplinary tumor board discussion or enrolment in a prospective clinical trial. Radiologically, TTs were labelled as malignant in four patients (66.7%) and as benign TTs in two others. The tails were recognised to be malignant due to the differing signal characteristics to reactive edema on mixed MRI sequences. The radiological evaluation correlated exactly with histological analysis, as satellite neoplastic cells were identified microscopically in the same four cases in which the TTs were designated to be malignant by MRI (specificity&sensitivity=100%). Surgical resection margins were microscopically positive in 50% of cases in the TTs themselves, and 75% of cases in which TTs were designated as malignant on staging MRI.

“The malignant nature of peri-lesional edema in MFS, also known as the TT, was accurately predicted in this small pilot study based on specific radiological features which correlated exactly with histologic identification of isolated tumor cells. These findings validate development of a larger prospective study to recruit additional patients with tumor tails beyond just MFS, in order to more robustly study the correlation between the MRI appearance and histological distribution of satellite sarcoma cells in peri-lesional edema in STS. We are already recruiting to this expanded radiological-histological investigation including evaluation of additional novel MRI sequences.

Background

Stem cell therapy has been suggested as a potential regenerative strategy to treat IVD degeneration and GDF6 has been shown to differentiate adipose-derived stem cells (ASCs) into an NP-like phenotype. However, for clinical translation, a delivery system is required to ensure controlled and sustained GDF6 release. This study aimed to investigate the encapsulation of GDF6 inside novel microparticles (MPs) to control delivery and assess the effect of the released GDF6 on NP-like differentiation of human ASCs.

Recurrent patellar instability is common in young and active patients. Medial patellofemoral ligament (MPFL) reconstruction with a single bundle hamstring graft is one method of surgical treatment for this problem. This is a retrospective case series of patients who underwent MPFL reconstruction by a single specialist knee surgeon between January 2009 and July 2014. Data was collected prospectively for the purpose of service evaluation. Recorded data included gender, age, length of rehabilitation, complications, Knee Injury and Outcome Score (KOOS) and International Knee Documentation Score (IKDC). Data is expressed as mean (range). 108 knees (103 patients) were identified (56 female, 52 male) with a mean age of 24.5 years (12–58). Mean length of rehabilitation was 3.2 months (0–11 months). Three patients required further revision surgery for recurrent instability. KOOS and IKDC scores improved from 44 (4–86) and 38 (2–81), respectively before surgery, to 77 (49–100) and 69 (37–95) after rehabilitation. MPFL reconstruction with a single bundle hamstring graft produces a marked improvement in knee function with a low recurrence of instability.

Purpose: In evaluating injury severity of acute medial collateral ligament (MCL) injuries, the current standard is to perform a history and physical examination and static MRI of the injured joint. With recent advances in dynamic MR imaging technology, we hypothesized that concurrent physical examination and dynamic MRI of the knee joint in patients with acute MCL injuries is feasible and would provide new insight into the injured joint kinematics while correlating to clinical and diagnostic imaging criteria for injury severity.

Method: 10 patients (5 male, 5 female) with isolated, unilateral, acute MCL injuries were prospectively enrolled in the study. An orthopedic surgeon performed initial physical examination and clinical grading. Dynamic MRI with concurrent physical examination was performed in a 1.5T wide-bore magnet and compared to the uninjured knee as a control. The dynamic MR imaging data was compared with morphologic MCL changes on static MRI, with dynamic examination of the contralateral knee and with the clinical grading of MCL injury. The width of the medial joint space and the opening angle between the femur and tibia were measured.

Results: Clinically, one patient had grade 1 and nine had grade 2 injuries. Using morphologic MRI criteria there were nine grade 2 and one grade 3 injuries. Mean and median medial opening angles of all affected knees was 2.8/2.5 mm and 2.8/2.6°, respectively, as compared to 1.8/1.8 mm and 2.2/2.1° in the normal side. Measurements of medial joint-space opening showed little quantitative difference between grade 1, 2 and 3 injuries. Interobserver agreement (intraclass correlation coefficients) varied from 0.9 to 0.93.

Conclusion: Dynamic MR imaging with concurrent physical examination is feasible and correlates to clinical and morphologic grading of severity. Our study suggests that traditional clinical grading systems of MCL injuries overestimate medial joint space opening.

Education is now recognised as a crucial component of the management of non specific low back pain. Mostly education is carried out informally in one to one consultations with health professionals. This has draw backs as it is costly, time limited, labour intensive and biased towards the discipline, training and beliefs of the clinician. The Back Book is a realistic alternative but provides very generic neutral information mostly promoting the message that pain isn’t damage.

We would see the process as one of the facilitation of knowledge acquisition rather than a formal teaching process. The latter implies engagement and responsibility on the part of the learner, rather than a pedagogic exercise by clinician or therapist.

We propose a group based, community delivered, interdisciplinary education module in which 4 different specialists contribute to an afternoon information session aimed at informing patients about: the causes of back pain from a non disease perspective, the complexity of pain perception, the biopsychosocial model, evidence based treatment of pain and some principles of paced pain management. The focus is on dispelling myths (such as the need for MRI scanning, surgery etc.) and enabling sufferers to make improved decisions about their care.

Data from over 120 patient attendances will be presented. These indicate high acceptability and satisfaction with 92% rating the afternoon as good or excellent and only 11% claiming the session had not helped them make better decisions about future treatment.

This model is simple, relatively low cost and accessible to primary care, which is acceptable and seemingly helpful to sufferers. It appears to be a viable model for presenting information to back pain sufferers early in their illness. The aim of this is to help them make more informed decisions and to see the need to incorporate self management approaches early in their history. More data are needed to ascertain whether these are achievable goals.

Idiopathic anterior knee pain (AKP) is common in adolescents and young adults. Most believe that the origin of the problem lies in the patello-femoral joint. Hamstring tightness has also been attributed as an important cause.

The aim of our study was to compare biometric parameters in patients with idiopathic AKP and controls. We also wanted to assess whether there was a difference in the relative electromyographic (EMG) onset times of the medial and lateral hamstrings.

We prospectively recruited patients with idiopathic anterior knee pain in the age group 11 to 25. Patients, but not the control population, had AP, lateral and skyline radiographs taken to rule out other pathology.

We had 34 patients (60 knees) with a minimum one year follow up. There was no difference in the symptoms of patients who attended physiotherapy as compared to those who did not. Patients with knee pain had significantly more hip external rotation (63 deg) as compared to the control (47 deg) group (p=0.001). Patients also had significantly more hamstring tightness (p=0.04).

Surface EMG was recorded (17 patients and controls each) from the medial and lateral hamstrings during 3 repetitions of a maximal voluntary isometric contraction exercise with the knee at 45° of flexion. The lateral hamstrings contracted 48.7 m.sec earlier than the medial hamstrings in patients as compared to controls.

AKP is a multifactorial and self-limiting disorder. Earlier contraction of the lateral hamstrings may cause tibial external rotation and contribute to the symptoms. Our data suggests that physiotherapy did not significantly alter the course of the condition. We believe that increased hip external rotation may contribute to the symptoms by increasing medial facet stress.

Introduction: Poor proprioception and imbalance between quadriceps and hamstrings have been suggested as causes for anterior knee pain. The aim of our study was to compare the proprioception of patients with anterior knee pain to a normal population and to compare the activity of quadriceps and hamstrings using electromyography (EMG) in the 2 groups.

Methods: Patients and controls between the ages 11–25 yrs were recruited into the study. The proprioception (stability index) of the patients and controls was tested using the Biodex stability system. This computerised system tests the ability of a person to balance his/her own body on a platform that moves in various directions. Surface EMG was recorded from the quadriceps and hamstrings during this test. EMG was also recorded as the patients and controls stepped onto a 20cm step. EMG activity was normalised to levels elicited during maximal isometric contractions.

Results: 18 patients and 27 controls were recruited.

We found no significant difference between the groups in the EMG intensity of vastus lateralis relative to biceps femoris, or vastus medialis relative to vastus lateralis, during the balance test or during the step up task (Mann Whitney U test all p> 0.05). We did not find any difference in the proprioceptive abilities of the two groups

Conclusion: We found no significant difference between the groups in the intensity of muscle contraction of the hamstrings relative to the quadriceps, i.e. no evidence for an imbalance in the patients. However the temporal relation between the two needs further investigation.